Endoscopic view of a hematoma of the nasal septum.

A 40-year-old woman came to the office after she had fallen and experienced nasal trauma. She had undergone a septoplasty and partial turbinectomies approximately 2 weeks prior to her fall. An x-ray after the trauma showed no nasal fracture. The patient complained of nasal obstruction, and endoscopy revealed a significant bilateral bulging of the septum (figure, A and B). A syringe was used to aspirate a large collection of blood. The diagnosis was a septal hematoma.

An incision was made in the right septal mucosa to facilitate further drainage. A Penrose drain was placed in the incision, and the nose was packed. The drain and the packing were removed 3 days later. At 1 week, the hematoma had resolved, although the mucosa was still edematous and the incision was still open (figure, C). Five months later, the patient was symptom-free and had patent airways bilaterally (figure, D).

In all cases of facial trauma, it is important to look for a nasal septal hematoma. Although this condition is rare, its complications can be severe. A septal hematoma can occur after nasal trauma if the force of the trauma ruptures the blood vessels that supply the septal perichondrium. If there is no mucosal tear, blood can collect in the space between the perichondrium and the quadrangular cartilage, causing a hematoma. The cartilage is thereby stripped of its nutrient-providing perichondrium. At the same time, the hematoma exerts a considerable amount of pressure on the septum. The combination of the pressure and the lack of nutrients causes necrosis and resorption of the septal cartilage. Because of a lack of cartilaginous nasal support, a "saddle-nose" deformity and nasal obstruction can result. The patient might also develop a septal perforation over the area of cartilage necrosis. [1]

Even more serious complications can arise if the hematoma becomes infected and causes an abscess. Septicemia and cavernous sinus involvement can develop by way of the emissary veins that drain the nasal septum. [2] This, in turn, can result in complications such as meningitis, cerebral abscess, subarachnoid empyema, and cavemous sinus thrombosis. [3]

Early diagnosis and treatment are key to avoiding the dire complications of a septal hematoma. When a hematoma develops, the septum becomes swollen and erythematous and obstructs the nasal passage (figure, A and B). Bilateral swelling might be observed if there is a fracture of the septal cartilage through which blood can track. Canty and Berkowitz found that nasal obstruction was the most common initial complaint associated with hematoma and abscess of the nasal septum. [3] The next most common symptoms were pain and rhinorrhea. Only three of their 20 patients had an associated nasal fracture.

Treatment of a septal hematoma involves making a drainage incision and prescribing antibiotic coverage. The drain is placed and the nose packed to prevent reaccumulation of blood. Any delay in diagnosis, and the subsequent development of cartilage necrosis, can result in a saddle-nose deformity that requires reconstructive nasal surgery.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group and the Section of Otolaryngology, Hospital of St. Raphael, New Haven, Conn. (Dr. Yanagisawa), and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa and Dr. Klenoff).

References

(1.) Bluestone CD, Stool SE, Kenna MA. Pediatric Otolaryngology. 3rd ed. Philadelphia: W.B. Saunders, 1996.

(2.) Ginsburg CM. Nasal septal hematoma. Pediatr Rev 1998;19:142-3.

(3.) Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg 1996;122:1373-6.